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psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
January 01, 2020 - Respiratory Depression (2)
• PCA can result in critical respiratory depression events with
significant consequences
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psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
August 29, 2021 - WebM&M Cases
To Dilute or Not Dilute: Drug Errors and Consequences
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psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
August 21, 2015 - As illustrated in this case, mobile device use in hospitals can also have risks and negative consequences
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psnet.ahrq.gov/web-mm/peripheral-iv-too-long
September 15, 2011 - delayed recognition of catheter infection by inexperienced staff, until the development of serious consequences
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psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
February 01, 2023 - WebM&M Cases
To Dilute or Not Dilute: Drug Errors and Consequences
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psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
May 01, 2008 - Treatment is critical for reducing the adverse health, social, and other consequences of alcohol use
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psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
August 21, 2016 - Without these efforts, more serious consequences might have resulted.
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psnet.ahrq.gov/web-mm/hidden-mystery
December 01, 2011 - Due to the high prevalence of obesity in the United States and its negative health consequences, understanding
-
psnet.ahrq.gov/node/865412/psn-pdf
March 27, 2024 - follow-up on abnormal laboratory results is not an uncommon system or process error and can
lead to dire consequences
-
psnet.ahrq.gov/node/49506/psn-pdf
March 01, 2006 - Clinical consequences of misinterpretations of
neuroradiologic CT scans by on-call radiology residents
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psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia
January 29, 2021 - WebM&M Cases
To Dilute or Not Dilute: Drug Errors and Consequences
-
psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
January 01, 2023 - Predictors and consequences of hematoma after thyroidectomy: an American College of Surgeons National
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
January 01, 2024 - a procedure (gastric bypass surgery), aimed at treating a chronic health condition (obesity and its consequences
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psnet.ahrq.gov/web-mm/volume-too-low-and-out
July 01, 2017 - He required 2 days in the intensive care unit but did not experience any long-term consequences.
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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - This system has failed and will continue to fail—sometimes with disastrous consequences.
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psnet.ahrq.gov/web-mm/blind-spot
July 30, 2020 - WebM&M Cases
To Dilute or Not Dilute: Drug Errors and Consequences
-
psnet.ahrq.gov/node/837791/psn-pdf
August 05, 2022 - 10-year-analysis-based-medical-malpractice-claims
exposure, false-positive results , psychological consequences
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psnet.ahrq.gov/web-mm/near-miss-bedside-medications
February 01, 2006 - relative to medical errors
Because of the lack of systematic mechanisms to capture errors and their consequences
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psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-missed-diagnosis
August 25, 2021 - able to:
Recognize common and serious pitfalls in diagnosis of Strongyloides and potential consequences
-
psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
January 01, 2023 - Failure to do so can lead to
tracheal and surrounding structure damage with severe clinical consequences